Emergency Contact and Life and Accident Insurance Beneficiary Designation
Please print clearly and return your completed form to URS Washington Division Human Resources, P.O. Box 73, Boise, ID 83729, or fax to 208-386-5631.
EMPLOYEE INFORMATION
Last Name First Name M.I Social Security Number Present Marital Status
K
Name Relationship
Single
K
Married
EMERGENCY CONTACT
Phone Number ) ( State Zip Code
Street Address
K Same as Employee
City
BENEFICIARY DESIGNATION
If additional space is needed, check here K and attach a separate sheet. Please name at least one primary and one contingent beneficiary. The primary beneficiary may be one person, more than one person, a trust or other legal entity. If the beneficiary is a trust, please provide the trust’s name and address, the date of the trust, and the trustee(s) name. If more than one primary beneficiary is named and no share percentages are indicated, benefits shall be paid to the surviving primary beneficiary(ies) in equal shares. If a percentage is indicated and a primary beneficiary(ies) does not survive you, the percentage of that beneficiary’s share shall be divided equally among the surviving primary beneficiary(ies). If no primary beneficiary survives you, benefits will be paid to your contingent beneficiary(ies). For multiple contingent beneficiaries, payments are made as described for primary beneficiaries. If no beneficiary is named, or no beneficiary survives the insured, settlement will be made in accordance with the terms of your group contract. Unless you specify otherwise, your beneficiary designations will apply to all of the following: Company Paid Basic Life Insurance, Optional Group Life Insurance, Company Paid Personal Accident Insurance, Supplemental Personal Accident Insurance, Company Paid Travel Accident Insurance. For Supplemental Personal Accident Insurance, the employee is the beneficiary for a covered spouse and covered dependent children. Payments to minors may be delayed. You may wish to work with an attorney if you wish to designate a minor as a beneficiary. If your designation is complicated, you may wish to consult an attorney to help ensure that the beneficiary designation reflects your intentions, is clear and unambiguous, and meets legal requirements. T. Rowe Price maintains beneficiary designations for the 401(k) Retirement Savings Plan and the Retirement Savings Plan for Puerto Rico Based Employees and reports them on quarterly statements. To make a change to your beneficiary designation for these plans, please call T. Rowe Price at 800-922-9945 for a form. Aetna maintains beneficiary designations for the Health Savings Account. To make a change, print a form from Virtual Office or contact Aetna at 800-752-0513.
Last Name Social Security Number First Name M.I. % Last Name Social Security Number First Name M.I. %
PRIMARY BENEFICIARY(IES)
Street Address
Street Address
City
State
Zip Code
City
State
Zip Code
Birth Date
Relationship
Birth Date
Relationship
Last Name Social Security Number
First Name
M.I. %
Last Name Social Security Number
First Name
M.I. %
CONTINGENT BENEFICIARY(IES)
Street Address
Street Address
City
State
Zip Code
City
State
Zip Code
Birth Date
Relationship
Birth Date
Relationship
If you enrolled in optional group life insurance coverage for your spouse, indicate the beneficiary for that coverage below. BENEFICIARY FOR SPOUSE Full Name Social Security Number Relationship OGL INSURANCE EMPLOYEE SIGNATURE
PER 327 (Rev 2008)
%
Employee Signature
Date
HR
Group Life coverage is issued by The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. CIGNA AND CIGNA Group Insurance are registered trademarks licensed for the use of insurance company subsidiaries of CIGNA Corporation. All products and services are provided by insurance company subsidiaries and not the corporation itself. As used herein, CIGNA and CIGNA Group Insurance refer to Life Insurance Company of North America. The group policy is subject to the laws of the jurisdiction in which it is issued.
Sign Here
This communication is not part of the official plan documents for any Company sponsored plan and is not intended to be an official interpretation of Plan provisions. This material describes only certain portions of some of the Company's benefit plans. It does not supersede the actual provisions of the applicable plan documents, which in all cases are the final authority. The terms of the plans cannot be amended or modified by this communication or oral statements. Only the Plan Administrator can interpret the terms of the plans. Although the Company intends to continue the plans described in this material, they may be amended (or even terminated) by the Company at any time without prior notice to or consent by employees, former employees, their dependents, or beneficiaries. To the extent this communication discusses aspects of health savings accounts (HSAs), it is not intended to be (and should not be construed as) tax advice. Moreover, HSAs are individually owned accounts (like IRAs) and are not part of a Company benefit plan.